Forms

Actives and Adjuncts

Active employees, Adjuncts, and COBRA participants who want to add a new dependent or remove a dependent (as needed), or change their benefit plan (with a qualifying life-changing event), should complete and submit an Enrollment/Change form.

Employees who do not want health and/or life benefits through LACCD for themselves or their dependents should complete and submit a Declaration of Declination of Health and Life Benefits.

Note: you should only complete and submit this form if you do not already have health/life benefits and are refusing them.Do not use this form if you already have dental, medical and vision benefits and want to remove a dependent from your benefits.

If you want to remove a dependent from your benefits, please complete and submit an Enrollment/Change form instead, and use Change in Dependent Coverage as your reason for completing the form along with the appropriate Event/Life Status Change.

Active Employees who wish to enroll in either Basic (District-paid) or Voluntary (employee pays the premium via paycheck deductions) Cigna Life Insurance should submit a Cigna Life Insurance application. Employees who apply for any life insurance benefit should also complete and submit Cigna's Beneficiary Designation form. Each time you wish to make a change to your beneficiaries, you should submit a new copy of this form. Employees who apply for voluntary life must complete and submit a copy of Cigna's Evidence of Insurabilityform.